Questions

Surgical Treatment Options for Erectile Dysfunction (ED)

Online Health Chat with Dr. Hadley Wood

November 11, 2011

Introduction

Cleveland_Clinic_Host: About 30 percent of men will have erectile dysfunction (ED) by the time they reach the age of 50. In the majority of cases, ED is not a disease but may be a symptom of an underlying health issues, such as atherosclerosis, diabetes, nerve disease or even psychological factors such as stress, depression and performance anxiety. Certain medications and conditions such as Peyronie’s disease also can lead to ED.

More than 95 percent of penile implants surgeries are successful, meaning they produce erections that enable men to have intercourse. Moreover, patient satisfaction questionnaires show that up to 90 percent of men who have undergone penile implants say they would choose the surgery again. While most men who have had this surgery can see a small surgical scar under the penis, other people will be unable to tell that a man has an inflatable prosthesis. In other words, most men would not be embarrassed in a locker room or public restroom.

Dr. Hadley Wood joined the Glickman Urological & Kidney Institute staff in 2009. She specializes in congenital anomalies of the genitourinary system in adolescents and adults, genital reconstruction, genitourinary prosthetics (male urinary incontinence and erectile dysfunction), urethral strictures, penile and urethral cancer, and radiation injuries to the bladder, prostate and urethra.

If you would like to make an appointment with Dr. Wood or any of the urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273, ext. 45600, or request an appointment online by visiting www.clevelandclinic.org/appointments.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Hadley Wood. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.

Age and Health

lucyintheskies: This is a very basic question. Do all men eventually experience ED as part of the normal aging process or is it a result of a health condition such as high blood pressure or stress?

Dr__Hadley_Wood: Aging and other problems, such as high blood pressure and vascular disease, tend to occur together. Even in healthy men without other medical problems, erections often can get weaker or of shorter duration, and this is likely due to accumulated damage to the nerves and blood vessels that supply input into the penis. In general, the better health a man is in from a vascular standpoint, the better his erections tend to be. Even with good health, however, many men encounter erectile problems with aging. It is important to note that weakened erections or erections of shorter duration tend to be the type of ED most amenable to medical therapy -- drugs like Viagra® (sildenafil citrate), Cialis® (tadalafil), and Levitra® (vardenafil) -- as opposed to surgical treatment.

hard_sell: My son is 21 and has told me that he is having ED problems. Isn’t he too young for this sort of thing? What would cause these problems in a young man? He is greatly distressed over this.

Dr__Hadley_Wood: ED is very rare in young patients. Most often, it is related to psychological factors, but there are medical reasons for ED as well. Even if psychological, there is treatment (with a sexual psychologist). We differentiate anatomic/physiological causes from psychological causes with a fairly in-depth evaluation that often involves ultrasound of the penis and/or wearing a device at nighttime to see if reflexogenic nighttime erections are normal.

joneses: I have trouble keeping an erection, even when in the middle of having sex. Is this a medical problem or more likely a mental problem?

Dr__Hadley_Wood: Please see my prior responses for some details about how we sort this out. It involves a fairly detailed history as well as (sometimes) more in-depth diagnostic testing.

Vascular Concerns

jake: I read about studies where pudendal artery stents are being used to help with ED. Can you please give me your thoughts? Are the studies promising?

Dr__Hadley_Wood: I don't have any experience with these stents, but will tell you that this doesn't make a whole lot of sense. I am assuming that you are referring to the INTERNAL pudendal, not the EXTERNAL pudendal (the latter uninvolved with erections). Blockage of this artery may, in rare instances, cause ED. Most ED, however, is not related to a blockage in this artery. It is typically due to microvascular or neurological compromise (e.g., from prostate cancer treatment or surgery, diabetes, etc.). I am not aware of the studies to which you are referring, but think that stenting (or surgical revascularization procedures) are only applicable in rare instances of ED.

big_bass: I am only 25 and have ED problems. A doctor finally diagnosed my problem as vascular. He suggested penile arterial bypass surgery as an option. What do you think of this surgery? Is because I am young a good thing?

Dr__Hadley_Wood: Please see my response to Jake. This evaluation is quite sophisticated. If imaging -- which is USUALLY an angiogram or an MRA -- shows blockage of the main arteries into the penis, he may be a candidate for revascularization procedures. These types of injuries are usually encountered after pelvic fracture or severe straddle-type injuries. These surgeries are done quite rarely, even at large centers of excellence, due to their rarity. We see a lot of surgical ED problems in our department and I am only aware of one such patient where this type of treatment was done in the past five to seven years or so. The take home message is to make sure you've seen a reputable urologist with a lot of experience in ED, and it probably wouldn't hurt to get a second opinion.

Implants

viro: I have been approved for a penile implant. I am looking for resources about the surgery: how the implant works, how it helps the penis lengthen from a flaccid state to fully erect. I'm a grower, not a shower. Also, how do I find how much experience a doctor has in this area?

Dr__Hadley_Wood: Dear Grower, Congratulations on your approval! If you have successfully navigated insurance approval for a prosthesis, then you've won half the battle! In all seriousness, there is a lot of information on the www about prostheses. Please know that a lot of this information is written and produced by the manufacturers of these devices, so take everything with a grain of salt. I think the best information on the devices comes from reading the instruction pamphlet for the device. It gives you the bare-bones facts about how the device works. If you have access to PubMed or other search engines for peer-reviewed medical/scientific literature, you can find research studies detailing outcomes (risks, durability, etc.) of these devices. A urologist with experience with these devices should be able to give you good information about this as well. We have excellent data on long-term outcomes for inflatable penile prostheses, since these devices have been available for decades.

As far as your post-implant length goes, you can expect that your inflated (erect) length will be your stretched penile length. That's the length of your penis when you grasp the head and pull out on it. For most men, that's not the length they were when they were 18. There is one device on the market that expands in length (as well as girth) and may increase the length by a half-inch or so, but for the most part, I recommend that men expect to have their erection approximate their stretched length post-op.

I would encourage you to find a doctor who places at least one of these devices per month on average. A local urologist or men's health specialist (and even some primary care doctors) often know who in the area is experienced with implants.

poddy: Can anyone get an implant or are there certain criteria that a patient would need to meet?

Dr__Hadley_Wood: The main limitation is cost. These devices (even without the cost of implantation and hospital care) are expensive. If you have an insurance company that will cover the device, are a Medicare patient, or just won the lottery, you're in luck. Other considerations with implantation revolve around the risk of implantation. If you have heart or lung problems that put you at risk for anesthesia, blood clotting problems that require you be on anticoagulation medications (which you will have to stop temporarily after implant), or other so-called "medical comorbidities," you will be at higher risk for complications around the time of surgery and afterward. The main risk after the immediate postoperative period is infection of the device (higher in re-implants, patients on immunosuppressive medications, and diabetics) or malfunction of the device (that's usually just bad luck). The only people who are typically not recommended for the device are people for whom there is not an "organic" (or physiological) reason for the ED. In other words, people who cannot get erections due to psychological factors, not medical factors, are not considered candidates.

no_mans_land: How long does an implant last?

Dr__Hadley_Wood: There is a little problem with this question in so far as the devices that are now 10 to 15 years old are no longer being implanted. Manufacturers continue to improve durability of these devices. A large study released in 2006 that looked at 10-year outcomes suggested that at 10-years, 75 percent to 81 percent of the devices are still in working order. It is my hope and expectation that a lower number of the (newer and improved) devices being implanted today will fail at 10 years. A device can fail at any point after implantation, but the rate increases with increasing duration after implantation. Infection risk (another reason for failure) is around 3 percent with the devices being implanted today.

Procedure

martin: What are the adverse effects to having surgery?

Dr__Hadley_Wood: Please see my response to poddy's question. The main risks can be divided into surgical and post-surgical. Surgical risks include risks of anesthesia (pneumonia due to being intubated, heart attack), damage to structures near where we are operating (the bladder, urethra, bowel in the pelvis, or vessels in the pelvis), postoperative pain, or a blood clot in the scrotum after surgery. Later complications include infection of the device (about 3 percent in the modern era), erosion of the device (which is usually associated with infection of the device), or malfunction of the device. If the device malfunctions, it can be removed and replaced in the same setting. If it becomes infected, in most cases, it is removed and then replaced after the infection has cleared (one to two months later). There is a protocol for removal of an infected device with re-implantation in the same setting in some circumstances of infection, but not when a patient is very ill or the device has eroded through. In these latter circumstances, we wait until everything heals prior to re-implantation.

rks9: What is the recovery like after having a penile implant?

Dr__Hadley_Wood: In our practice, we instruct patients not to participate in any vigorous sports or to lift anything heavy for six weeks. Many men, however, return to work or routine activities in a couple of weeks. Every man experiences pain differently. The majority state that the pain is substantially improved around the two-week mark. Before that, it is typical to need some pain medications -- particularly at the end of the day. We typically activate (or teach men how to use) the prosthesis six weeks after surgery. Initially, we instruct them to inflate and deflate the device three times a day or so and not use it for recreational activity at first. There is often a little pain or ache at maximal inflation during this initial period. After a couple weeks of inflating and deflating, there is usually little or no pain with inflation. At that point, we recommend that a man proceed with use of the device for intimacy.

nancy: My husband has ITP with low platelet count, is on defibrillator with timed contraction, prostate cancer treated with radiation, now on papaverine injections at 81. Is he a candidate?

Dr__Hadley_Wood: Please see my other answers regarding the risks. Certainly, low platelet count is a risk factor for bleeding after surgery. Typically, we do not recommend elective surgery with a platelet count < 20K. I would recommend you see a urologist so he/she can assess your husband's risk and, together with his hematologist and cardiologist, determine what the risk would be to proceeding with surgery.

Options

jimk: Can you please talk about being banded as a treatment for ED?

Dr__Hadley_Wood: By "being banded," I am assuming that you are referring to placement of a ring around the base of the penis to prevent blood flow out of an erection. This is a very old treatment for ED (there are reports dating back to medieval times) that still can work for many men. Successful use of this technique requires that a man can use a vacuum device or achieve a partial erection on his own. The ring or band augments the erection. This is also a relatively low-cost and low-risk treatment, so if you can make it work, by all means go for it. I would advise against putting any solid rings around the penis, however, as they can cause swelling distal to the ring and become difficult to remove.

Arizona50: My husband has experienced ED since his radiation seed treatment for prostate CA (cancer) eight years ago. Up until the last year, he could successfully achieve an erection with the help of oral medications. They no longer seem to give him a full erection. Would surgical treatment be an option, even though he may have sustained nerve damage when originally treated for CA? Would complications be anticipated due to the radiation treatments?

Dr__Hadley_Wood: Radiation treatments tend to demonstrate a cumulative effect on the nerves with time, so worsening function several years afterward is typical. Progression of other causes of ED -- hypertension, hyperlipidemia, diabetes, etc. -- also contributes to worsening function. When medications fail, the next options are injections of medications directly into the penis or placement of a medication into the urethra (tube that drains the urine) or a prosthesis. Having had radiation prior to placement of a prosthesis may make implantation more difficult, but won't disqualify a patient for the surgery.

Medication Safety

cpiner: Are there any other medications a person might be taking that would prevent someone from taking Viagra®?

Dr__Hadley_Wood: Yes! There are some very important contraindications to drugs like Viagra®. A common drug for the prostate -- Flomax® (tamsulosin) -- is one such drug that requires that the two drugs be taken at a 4-hour interval. Another very important one is any type of nitrate medication. I would recommend you review the drugs you are currently taking with your doctor prior to use of any of the Viagra®-type medications, even if you are obtaining these medications from another source (mail order or buying it off the street -- both not advisable but unfortunately common).

Information

Goldwater: How does one bring up the topic of ED with the doctor? What kinds of questions should I ask?

Dr__Hadley_Wood: In short, most doctors think about ED as part of the whole well-being of the patient -- not only because a healthy sexual life often translates to a healthy patient -- but literally that ED may be a harbinger of other vascular problems, such as heart disease. So, this is very important for you to talk about with your doctor. It is unfortunate that some do not directly ask, but you should volunteer it if you feel comfortable. And if you don't, by all means ask for a referral to a urologist or ask a friend for the name of a good urologist. We talk about ED all day long! When we ask about ED, we typically ask very specific questions about your sexual health (like whether the erection lasts long enough or can get firm at all, whether you experience morning erections, etc.). This is not because we have some abnormal fetish, but because it gives us an idea about how to proceed with evaluation and treatment.

hemi: Are there resources available to men who are considering an implant where they can talk to someone who actually has one and how they did with it?

Dr__Hadley_Wood: Not sure if you're from the Cleveland area, but we are having two talks next week regarding erectile dysfunction and urinary incontinence following prostate surgery. A gentleman will be speaking about his experience with having an implant. You can e-mail urology@ccf.org for more information.

photo_shop: As I read your answer to mine and other's questions, I see that things we read on the Internet do not always make any sense to you as doctors. How do you know what information you read about is credible? I've read other people's posts on forums and in chat rooms and they talk about treatments that worked for them. How do you make sense of it all?

Dr__Hadley_Wood: This is a field for which there is some medical evidence, a fair amount of lore, and some "home remedies" that may work but aren't necessarily tested in a FDA-formalized manner. I can only speak to those that can be medically recommended and beg that you use your judgment about the others. Home remedies can be both dangerous (particularly oral or injectable agents) and unproven. If you have a doctor you can trust, I implore you to discuss your ideas/concerns with him/her. Information on the Internet (including this!) is a matter of opinion and without any control. You need to do your homework to ensure that the sources from which you are obtaining your information are credible.

General questions

photo_shop: I’ve read about PNE (Pudendal Nerve Entrapment) as a possible reason for ED. What are your thoughts on this and how would it be treated?

Dr__Hadley_Wood: I am not sure that I understand the question. I think that pudendal nerve entrapment is an entity by which the external pudendal nerve was entrapped as it exits the pelvis (in Adcock’s canal). This is not the nerve responsible for erections and, therefore, this doesn't really seem to make sense. This type of injury can cause pelvic pain and possible scrotal pain, but I cannot postulate how it would impact erections. The ED was secondary to severe pain in the pelvis.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Hadley Wood is now over. Thank you again Dr. Wood for taking the time to answer our questions today about Surgical Treatment Options for Erectile Dysfunction (ED).

Dr__Hadley_Wood: Thank you for chatting today

More Information

If you would like to watch a video that explains a penile prosthesis procedure, please visit www.clevelandclinic.org/glickman. Scroll down to the video section, and under "Urology," choose the video titled "See How Penile Prostheses Can Help." If you would like to make an appointment with Dr. Wood or any of the urologists who specialize in penile implants, please call 800.223.2273, ext. 45600, or visit www.clevelandclinic.org/appointments.

You may request a remote second opinion from Cleveland Clinic through the secure Cleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.

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